| NPI | 1336854074 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WI 15592-33) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CO APN.0998091-NP) |
| Enumeration Date | 2023-01-17 |
| Last Update Date | 2024-08-15 |